Waterpipe Smoking among University Students in Sulaimaniyah, Iraqi Kurdistan: Prevalence, Attitudes, and Associated Factors

Background: Waterpipe smoking is increasingly becoming the most common method of tobacco use among adolescents in the Eastern Mediterranean Region. This study was undertaken in Iraqi Kurdistan to estimate its prevalence among students and investigate attitudes and factors associated with it. Materials and Methods: In a cross-sectional survey at Sulaimani Polytechnic University, 1160 students were approached in a two-stage design using a self-administered questionnaire. Data was entered into Epidata and analysis was done in Stata. Results: Prevalence of cigarette smoking was 10% and waterpipe smoking was 28% (male 49%, female 10%). Waterpipe smoking was initiated prior to joining the university in 74% of the cases and 22% of waterpipe smokers smoked every day. The most common place for smoking was coffee shops (52%) and 71% of smokers shared the pipe. The significant risk factors were smoking cigarettes (OR 10.3, 95% CI 7.0–15.0), male gender (OR 5.7, 95% CI 3.9–8.2), non-Kurdish ethnicity (OR 3.0, 95% CI 1.6–15.9), city residence (OR 1.5, 95% CI 1.0–2.1), and use of alcohol and other substances (OR 2.8 95% CI 1.4–5.6). Conclusion: Waterpipe smoking is highly prevalent among students in Iraqi Kurdistan, especially among males, and is becoming a public health problem. Tobacco control interventions should be designed specifically to address this problem among adolescents and the youth.


INTRODUCTION
According to the WHO, there are over 1 billion smokers worldwide with a global prevalence of 21% among adults in 2013 (1). Waterpipe smoking (WPS) has increasingly become a common method of tobacco use worldwide, and it is the most common method of tobacco use among adolescents in the Eastern Mediterranean Region (EMR) according to Maziak et al. study (2). A number of studies have been undertaken in several countries of the region to estimate the prevalence of WPS and associated attitudes especially among adolescents and the youth and have reported varying prevalence rates. A study in Oman reported a prevalence rate of 9.6% among adolescents in 2008(3), while another from Syria reported 23.5% among university students in the same year (4). Studies in other countries have reported similar or higher rates such as 6% among adolescents (5) and 51% among university students in Iran (6), 29.5% among students in Lebanon (7), and 30% among students in Jordan (8). It can be noted from the literature that the prevalence of WPS has been increasing in the EMR countries. Although WPS was traditionally present in Iraq for the more affluent people, coffee shops Therefore, the current study was undertaken to address this gap and estimate its prevalence among university students and investigate associated attitudes and factors.
This information could be useful for designing public health interventions and further research to address the health issue.

MATERIALS AND METHODS
A cross-sectional survey was undertaken at Sulaimani Polytechnic University's 10 campuses located in different towns of Sulaimaniyah province, Iraqi Kurdistan. This university enrolls around 13000 students at its 8 institutes (2 years of education) and 5 colleges (4 years of education).
Sample size calculation was done in EpiInfo version 7.0 using the following parameters: reference population of 7110 students (1 st year students were not included in the study), estimated WPS prevalence of 10%, 2% error level, and a design effect of 1.5. This calculation gave a sample of 1160 students. Sampling was done in three stages. At the first stage, the sample was divided proportionate to population (student) size among colleges and institutes; at the second stage the sample of each college/institution was divided proportionate to population size by gender; and at the third stage individual students were selected using simple random sampling. A self-administered questionnaire was developed in the local language based on a review of previous studies (6,9,10 Reported parental cigarette smoking was 23%.      Factors that were significant at 0.2 or less were included in a multivariate logistic regression. Table 6 shows adjusted odds ratios or factors that remained significant at the multivariate level when a multiple logistic regression model was used. The statistically significant factors were male gender, ethnicity, residence in Sulaimani city, smoking cigarettes, and alcohol use.

Factors associated with waterpipe smoking
Compared to students not smoking cigarettes, cigarette smokers had 10-fold odds of being waterpipe smokers.
Males had 5.7 times the odds of being waterpipe smokers compared to females. Similarly, residence in Sulaimani city, ethnicity, and consumption of alcohol were also independently significant risk factors for WPS (see Table   6).   for females (19), which is comparable to our findings.
Other risk factors for WPS reported in the literature include higher socioeconomic status and better parental education (14). However, these factors were not included in the present study.
The study has some strengths and limitations. This is the first study undertaken in Iraqi Kurdistan to investigate prevalence and associated factors of WPS. Although the study was conducted at only one university, it is one of the biggest universities in terms of the number of students and spread of campuses throughout the governorate.